Specialised 12-week course of gentle beginners Yoga
‘Yoga for Healthy Lower Backs’ (YHLB)1
An evidence-based, cost-saving, health-promotional, long-term
treatment option for a prevalent chronic condition
with integrative health and social care potential
Objectives and Potential of ‘Yoga for Healthy Lower Backs’ Programme:1. Improve the health of those with chronic and recurring low back pain.
The charity, Arthritis Research UK (funders of the original high-profile
yoga for back pain randomized controlled trial) and The University of
York support this research ‘translational’ project (Annals Intern Med3).
2. Show best practice partnership-working during implementation of
integrated services - perhaps with 3-way (NHS, Council and patient)
sharing of costs in commissioning of evidence-based YHLB courses. Save
NHS, Councils, Government, societal and economic costs by offering a
high value, self-management, educative treatment option with the
potential to offer wide-ranging, long-term, positive outcomes. It showed
an average 70% reduction in work absenteeism over 12 months,
showing how the YHLB course motivates and teaches good selfmanagement skills (Spine2).
3. Help prevent ‘NHS patients’ with chronic/ episodic/ recurring low back
pain in Primary Care settings ‘falling into’ costly Secondary Care. Our
research showed YHLB would be likely to be cost-effective if offered
within the NHS compared to current care pathway treatments2.
4. Give a ‘hand up out of’ NHS Secondary Care, with YHLB’s gentlyprogressing, multi-modal (biopsychosocial) approach, to patients with
non-specific, but nevertheless disabling, low back pain3.
5. Build patient ‘resilience’ to improve quality of life, and to help people to
become more active whilst living longer, happier and healthier lives.
YHLB proactively addresses ‘secondary preventative care’, i.e.
improvement and prevention of co-existing conditions along with back
pain, e.g. diabetes, obesity, depression, high blood pressure, and stressrelated and musculoskeletal conditions.
Research Background to Yoga for Low Back Pain and YHLB
With most cases (85%+) of back pain being of ‘non-specific’ origin, and with
75% of those with back pain re-presenting to their GP with another episode of
pain within 12 months, a patient-centred, long-term self-management, multimodal, educational approach that addresses this costly, multi-faceted
recurring condition is required.
Searches on PubMed reveal that much research has been done to show how
specialised yoga is now considered to be a good option for low back
pain2,3,4,5,6,7,8. Several systematic reviews and meta-analyses of yoga for back
pain (including some done prior to this University of York trial) virtually all
point to the use of yoga as an appropriate safe and efficacious
treatment9,10,11,12,1314,15,. In the May 2013 H. Cramer et al paper10 states
‘DISCUSSION: This systematic review found strong evidence for short-term
effectiveness and moderate evidence for long-term effectiveness of yoga for
chronic low back pain in the most important patient-centered outcomes. Yoga
can be recommended as an additional therapy to chronic low back pain
patients. In fact yoga is being used to good effect in several countries (e.g.
Sweden, USA). The University of Aberdeen ‘Complementary and Alternative
Therapies Report’16 commissioned by Arthritis Research UK gave yoga top
ratings (Green for safety and 4/5 for efficacy, based on quality research
evidence, prior to our significant RCT which adds more efficacy and costeffectiveness strength).
YHLB Yoga Programme Designed for and Used Successfully in University of York
/ Arthritis Research UK Randomized Controlled Trial (RCT)
Building on previous yoga research (most noteworthy 2005 and 2009 RCTs
Refs), from 2007 the charity Arthritis Research UK funded York Trials Unit in
The Department of Health Sciences at The University of York to carry out a
multi-centred RCT into yoga’s effectiveness and cost-effectiveness for back
pain17. For this rigorously-conducted trial, NHS patients were recruited from
39 UK GP surgeries and 20 yoga teachers were trained in YHLB. In 2011 a
leading international journal, The Annals of Internal Medicine published the
efficacy research findings3. These statistically and clinically significant
‘intention to treat’ trial results show that offering the ‘Yoga for Healthy Lower
Backs’ programme is a safe and effective option for the long-term, and one
that ‘clinicians and physicians should be comfortable recommending to those
with a history of low back pain’. Furthermore its Forest Plot3 showed it to be
one of the best similarly rigorously-tested treatments currently available for
the chronic and recurring condition of low back pain (better than:
manipulation by osteopaths/ chiropractors/ physiotherapists; exercise classes
taught by physiotherapists; manipulation followed by physiotherapist-taught
exercise classes; massage; usual GP care; self-care back education book; backcare booklet; Cognitive Behavioural Therapy; 6 individual sessions of Alexander
Technique (those who attended 6+ YHLB classes according to the 5th published
paper concerning YHLB in ‘Physiotherapy’ journal18 in 2014 fared better than
24 individual sessions of Alexander Technique).
Which yoga? – YHLB = a uniquely evidence-based, high quality programme.
The original research was designed to offer a ‘yoga package of care’ that could
be rolled out for the benefit of the UK. There are many forms of yoga and
therefore common ground and a consistent ‘best practice’ approach to
delivering the yoga programme was paramount in order to make the research
‘generalizable’ and transferable. Several styles of yoga would not be suitable
for those with painful conditions, nor for Beginners, whereas YHLB is designed
to be an ideal and appropriate yoga starting-point. Acknowledging this, yoga
specialists, back pain experts and academics encouraged the use of an
identifiable name for the trial’s yoga programme from the outset. Reinforcing
and reflecting this, the peer-reviewed ‘Annals of Internal Medicine’ journal
published ‘Yoga for Healthy Lower Backs’ as a heading within the 2011 paper.
With the support of Arthritis Research UK and The University of York a social
enterprise (Yogaforbacks.co.uk1) was initially set up in 2011 to educate about
and ensure a raising of awareness of the research and the yoga programme’s
potential, a ‘keeping to the evidence-base’ and an availability of the
educational resources. ‘The Yoga for Healthy Lower Backs Institute’1 exists to
continue to train already qualified and experienced professional yoga teachers
from a variety of schools and methods in the YHLB programme. The Institute
offers quality-assurance with the ethos of ‘sharing whilst maintaining high
standards and keeping to the evidence-base’ (in relation to training, delivery of
the YHLB programme, and use of educational resources). On top of the YHLBtrained yoga teachers’ own association/organization/school’s requirements
and procedures, the YHLB Institute adds extra layers of regulation, clinical
governance, monitoring and evaluation, for unified and professional provision.
Long-Term, Multi-Modal Self-Management with a single 12-week course.
The YHLB programme was designed to give the course attendees the tools for
lifelong self-management:- Extensive YHLB manual/book; Relaxations audio
CD; Home practice hand-outs and homework timetable; Pain-relieving pose
sheet; Postural advice; Philosophical ideas, relaxation and breathing
techniques to aid mental wellbeing (yoga has been shown to reduce
depression and stress); Back function education to promote understanding of
healthy movement and lifestyle. At the 12-month follow-up point the majority
of attendees were still practising yoga at home the recommended twice a
week for 30 minutes, i.e. we know we taught attendees to enjoy keeping
physically and mentally ‘fit’.
Cost-Effectiveness & Workplace Absenteeism Reduction - Published Research.
In 2012 ‘Spine’ journal published the Economic Evaluation paper for The
University of York’s trial2. This showed the ‘Yoga for Healthy Lower Backs’
‘single dose’, specialised 12-week yoga programme:- 1. would be likely to be a
cost-effective treatment for chronic low back pain (compared to a package of
physiotherapy or hospital clinics); 2. reduced work absenteeism substantially
(participants in the yoga group had on average only 3.83 days off work over
the 12 months studied compared to 12.29 days in the non-yoga control group);
3. is a dominant treatment for society.
Integrative Model ‘Ready to go’ Programme with Cost-Savings Potential for
NHS, Councils and Workplaces.
Some NHS regions, have allocated low back pain as a condition for which care
pathways need to be improved, e.g. Cornwall. YHLB was offered in the original
research at the point of GP referral (using YHLB Inclusion/Exclusion criteria)
and it is envisaged that this practice will become more widespread in the UK
soon especially after a GP visit using the STartBack19 questionnaire tool or as
part of a multi-disciplinary team. YHLB can be especially good for Yellow Flags
and YHLB teachers know how to refer back/on and to recognize Red Flags. Our
research shows YHLB offers a good first-line treatment option. The userfriendly 12-week YHLB course is available currently throughout the UK and
offers self-management of a prevalent long-term chronic condition, with
added health and wellbeing benefits beyond that of improved back health. It
offers communities and Councils high value, long-term health/ societal/
economic benefits. Arthritis Research UK20,21 may support more evaluative or
qualitative research to commence this integrative process, e.g. YHLB for over
65s. The course is likely to be particularly helpful to an aging population
and/or those with injuries, as it has a gentle and paced approach to physical
fitness, offers group setting support, and addresses mental health and
wellbeing. YHLB works holistically to improve co-existing stress-related
conditions that could later lead to serious or chronic pathology (eg. headaches,
IBS, obesity, high blood pressure, anxiety, diabetes, respiratory problems).
Yoga is being used to good effect within other healthcare systems, and it
would seem reasonable to suggest that steps should be taken for the UK to
benefit soon from this 2007-2010 UK-based research. Published research
showed that this specialised course would be likely to be cost-effective if
offered within the NHS at an estimated cost of £292 per person2. Dependent
on help with room provision (GP surgery waiting-rooms in the evenings?),
bookings (Choose and Book), and administration (records and outcome
measuring) we would be likely to be able to offer the course for less (£200-250
for the full 12-week course). It is being offered in the private sector at an
average price of £225 per person and although this offers good value for
money, it does not make it ‘inclusive’, i.e. some people are unable to afford it.
The Yoga for Healthy Lower Backs Institute teachers are ready to work within
the public sector (some already are). They could usefully collaborate on
innovation work, e.g. Pioneer Project / Kings Fund / Better Care Fund.
Please contact Alison Trewhela on info.YHLB@gmail.com or
yhlb@orangehome.co.uk.
Alison Trewhela, Cornwall, UK
Lead Yoga Consultant on The University of York yoga trial management team
(2006-Present), Designer of the YHLB programme, YHLB teacher trainer, YHLB
teacher).
Specialist Tutor in Yoga for medical students (since 2004), University of Exeter
Medical School.
Specialist Advisor in Yoga for Institute of Complementary and Natural
Medicine.
Award Winner of ICNM’s 2013 ‘Most Outstanding Contribution to
Complementary Medicine.
Senior Practitioner in Yoga on British Register for Complementary
Practitioners.
Director and Principle Tutor of ‘The Yoga for Healthy Lower Backs Institute’.
‘YOGA for Healthy Lower Backs’ social enterprise www.yogaforbacks.co.uk.
Brief Case Studies
Case Study 1
A retired fireman, ex-military, with over 40 years of severe back pain is
delighted with the amazing results he has experienced from just 12 simple
classes of Yoga for Healthy Lower Backs.
Case Study 2
A Cornish trial participant in The University of York’s trial, who began the YHLB
programme unable to work with severe back pain and accompanying
depression, found that by week 11 of the 12-week programme she was “95%
cured” of the herniated disc that had at last been diagnosed after a long delay.
Case Study 3
A lady with severe and disabling back pain spent almost a year in agony before
receiving surgery for her unrelenting herniated disc. After surgery she was
unable to regain confidence in her ability to live happily in her body and was
regularly attending hospital Pain Clinic appointments. After only a few classes
of the Yoga for Healthy Lower Backs programme, she felt optimistic about
finally gaining control over her health and fitness again.
Case Study 4
A man who had been unable to work after a traumatic back injury found that
attending the gradually progressing Yoga for Healthy Lower Backs course was
the clearest and most positive experience out of the multiple and confusing
treatment options he had been offered and tried. He described it as ‘turning a
corner at last’.
Case Study 5
A lady with back pain and arthritis says that the 12-week YHLB programme has,
in her late 60s given her the tools to know how to look after her health for the
long-term. She practices the yoga wherever she travels and wishes more
elderly people could be given this opportunity.
Case Study 6
A physiotherapist back pain specialist attended the YHLB course for
professional reasons and was impressed with the evidence-base, structure,
pace, clarity of instruction, appropriateness, efficacy potential for a range of
conditions, and the educational resources that aid self-management.
References:1. www.yogaforbacks.co.uk
2. ‘A pragmatic multicentered randomized controlled trial of yoga for chronic low back
pain: economic evaluation.’. Chuang LH, Soares MO, Tilbrook H, Cox H, Hewitt CE,
Aplin J, Semlyen A, Trewhela A, Watt I, Torgerson DJ. Spine (Phila Pa 1976). 2012 Aug
15; 37(18):1593-601.
3. ‘Yoga for chronic low back pain: a randomized trial’. Tilbrook HE, Cox H, Hewitt
CE,Kang’ombe RA, Chuang LH, Jayakody S, Aplin JD, Semlyen A, Trewhela A, Watt I,
Torgerson DJ. Ann. Intern. Med. 2011 Nov 1; 155(9): 569-78
4. ‘Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low
back pain.’ Williams K1, Abildso C, Steinberg L, Doyle E, Epstein B, Smith D, Hobbs G,
Gross R, Kelley G, Cooper L. Spine (Phila Pa 1976). 2009 Sep 1; 34(19):2066-76.
5. ‘Comparing yoga, exercise, and a self-care book for chronic low back pain: a
randomized, controlled trial.’ Sherman KJ1, Cherkin DC, Erro J, Miglioretti DL, Deyo
RA. Ann Intern Med. 2005 Dec 20; 143(12):849-56.
6. ‘Yoga for chronic low back pain in a predominantly minority population: a pilot
randomized controlled trial.’ Saper RB1, Sherman KJ, Cullum-Dugan D, Davis RB,
Phillips RS, Culpepper L. Altern Ther Health Med. 2009 Nov-Dec; 15(6):18-27.
7. ‘Effect of short-term intensive yoga program on pain, functional disability and spinal
flexibility in chronic low back pain: a randomized control study.’ Tekur P1, Singphow
C, Nagendra HR, Raghuram N. J Altern Complement Med. 2008 Jul;14(6):637-44.
8. ‘The impact of modified Hatha yoga on chronic low back pain: a pilot study.’
Galantino ML1, Bzdewka TM, Eissler-Russo JL, Holbrook ML, Mogck EP, Geigle P, Farrar
JT. Altern Ther Health Med. 2004 Mar-Apr;10(2):56-9.
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Baxter GD. Musculoskeletal Care. 2013 Dec; 11(4):203-17.
10. ‘A systematic review and meta-analysis of yoga for low back pain.’ Cramer H1,
Lauche R, Haller H, Dobos G. Clin J Pain. 2013 May; 29(5):450-60.
11. ‘Effects of yoga interventions on pain and pain-associated disability: a meta-analysis.’
Büssing A1, Ostermann T, Lüdtke R, Michalsen A. J Pain. 2012 Jan;13(1):1-9
12. ‘Yoga as a Treatment for Low Back Pain: A Review of the Literature.’ Erik J. Groessl
Marisa Sklar and Douglas Chang. ‘Yoga for Chronic Low Back Pain: New Evidence in
2011’. Groessl EJ 2012. J Yoga Phys Therapy 2:e108. (http://omicsonline.org/21577595/2157-7595-2-e108.php)
13. ‘Unloaded movement facilitation exercise compared to no exercise or alternative
therapy on outcomes for people with nonspecific chronic low back pain: a systematic
review.’ Slade SC1, Keating JL. J Manipulative Physiol Ther. 2007 May;30(4):301-11.
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V. Curr Rev Musculoskelet Med. 2008 Mar;1(1):39-47
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Ernst E. Clin Rheumatol. 2011 Sep; 30(9):1257-62
16. ‘Practioner-based complementary and alternative therapies for the treatment of
rheumatoid arthritis, osteoarthritis, fibromyalgia and low back pain’ University of
Aberdeen. Free download at
http://www.arthritisresearchuk.org/shop/products/publications/patientinformation/living-with-arthritis/cat-report.aspx#sthash.ZuwZRIsI.dpuf
17. University of York yoga trial website www.yogatrial.co.uk 2011
18. ‘Compliance effects in a randomised controlled trial of yoga for chronic low back
pain: a methodological study.’ Tilbrook HE, Hewitt CE, Aplin JD, Semlyen A, Trewhela
A, Watt I, Torgerson DJ. Physiotherapy. 2013 Dec 4. pii: S0031-9406(13)00118-1
19. ‘The effectiveness of a stratified group intervention using the STarTBack screening
tool in patients with LBP--a non randomised controlled trial.’ Murphy SE1, Blake C,
Power CK, Fullen BM. BMC Musculoskelet Disord. 2013 Dec 5;14:342
20. ‘Got back pain? Try yoga.’ Arthritis Research UK January 2012.
http://www.arthritisresearchuk.org/arthritis-information/arthritis-todaymagazine/155-winter-2012/yoga-trial.
21. ‘Yoga a cost-effective treatment for back pain sufferers?’ Arthritis Research UK August
2012. http://www.arthritisresearchuk.org/news/press-releases/2012/august/yoga-acost-effective-treatment-for-back-pain-sufferers.aspx